Increase Access to Non-Pharma Therapies

 

Introductory Paragraph

This objective focuses on Non-Pharmacologic Pain Care (NPPC). There are three avenues for increasing the use of NPCC alternatives. One pathway is for the medical community to promote alternatives that have been verified as effective. The second and most most powerful leverage point lies with changing the insurance standards that provide reimbursement for NPCC. The third pathway is for the public to begin to express their desire for NPCC.

Key Information

Currently, most insurance plans do not cover most non-medication therapies. Working with insurance companies to put more alternative and complementary pain therapies in their formularies and services covered can decrease the prescribing of opioids for pain. Using such therapies that are alternatives to opiates can prevent patients from having opiates introduced into their bodies, which is one of the best ways to reduce the number of people who try an opiate. Using alternate therapies can also prevent unpleasant adverse effects of opiates, such as nausea and vomiting. Often times, people using opiates use other illicit and addicting substances to treat their nausea such as marijuana, producing a cycle of dependency on those two drugs that is difficult to break. Also, patients with Substance Use Disorder are more likely to try other addicting drugs, making treatment and quitting harder. There are many benefits of using alternative therapies. As many fields are being studied, they appear to be a promising way to help deal with the opioid crisis. Considering alternative and complementary therapies in today’s society where patients often have complicated medical histories and polymedication can also help them avoid adverse drug reactions and help preserve the health of various organs by putting less stress on liver (which metabolizes the drug and detoxifies the body) and kidney (which excretes the drug). Using therapies that have less toll on the body can help our patients stay healthier and overall improve their quality of life.

Current Status
Attorneys general (AGs) from 37 states have let the insurance industry know that the fight against the nation's opioid crisis won't be won unless health care providers are encouraged to prioritize nonopioid pain management options, including physical therapy, over opioid prescriptions for the treatment of chronic, noncancer pain.
Brandeis University Professor Dr. Andrew Kolodny said efforts to limit opioid prescribing in recent years have been positive steps but warns that there are about 10 million to 12 million patients in the U.S. who have been on painkillers for years and need alternative therapies to offset the potential damage that could be caused by being cut off cold turkey.

Complementary Health Approaches

• Acupuncture
• Chiropractic Care and Spinal Manipulation
• Massage Therapy
• Stretching and Fitness Techniques to Minimize Pain
• Mindfulness and meditation-based therapies
• Tai Chi and Qi Gong
• Yoga
• Biofeedback
• Transcutaneous electrical nerve stimulation, or TENS.

Benefits of Active Self-Care Therapies

In contrast to medication-based therapies, many NPPC strategies involve significant patient participation and a commitment to self-care. NPCC strategies tend to increase self-efficacy in managing pain and correlate with improved mood and outcomes in many chronic conditions, including pain. For example, the military has studied “active self-care therapies” as a category of pain management that may be of value in an integrated, multi-modal approach.

Education for Future Doctors

When future doctors go through school, there seems to be very limited education detailing pain and pain management. Pain curricula in medical school education for both MDs and DOs in the U.S. ranges from 1-31 hours during the 3-4 year curriculum, with a mean of 11.13 hours. Thus, the current training system has left primary care practitioners with inadequate tools to deal with some of the most common problems doctors will come across during their years of practice. Any meaningful effort to improve pain management will require a basic culture shift in the nation’s approach to mandating pain-related education for all health professionals who provide care to people with pain.

One possible solution is cross-training between fields. Many, if not most, pain clinics are still housed in anesthesiology clinics, but fellowship pain training can now be pursued not only by anesthesiologists but other specialists in neurology/psychiatry, PM&R, and internal and family medicine. Physicians who receive fellowship training in pain care learn interventional pain strategies that originated in regional anesthesia and acute pain care, including non-pharmacological options. The expansion of these strategies, which are the mainstay of anesthesiology and acute pain practices, to chronic pain care have had more modest success in carefully selected patients.

Relevant Research

• This article is based upon interviews with eight groups of patients, nurses and primary care providers to identify barriers and successes in the use of NPPC treatments in chronic pain.

• This white paper, "Evidence-based Non-Pharmacological Strategies for Comprehensive Pain Care," examines evidence for NpPC therapies effective, including acupuncture therapy, massage therapy, osteopathic and chiropractic manipulation, meditative movement therapies Tai chi and yoga, mind body behavioral interventions, dietary components and self-care/self-efficacy strategies.

Impactful Federal, State, and Local Policies

Insurance and Coordinated Care
Coordination of care across disciplines and access to nonpharmacologic care have not been optimized in the current system in most states and territories, and improvement to these systems could help reduce opioid use. There are a few state Medicaid policy initiatives aimed at increasing access to effective nonpharmacologic therapies as a first line treatment for pain conditions. For example, the Oregon Health Plan (OHP – Oregon’s Medicaid program) covers acupuncture therapy, chiropractic and osteopathic manipulation, physical therapy and cognitive behavioral therapy for all back conditions. Vermont’s legislature is piloting a program where they will cover acupuncture therapy for back pain in a Medicaid population and monitor health outcomes and cost-effectiveness. Such programs are promising and there is hope that with more interventions like this, the number of opioids being prescribed will decrease.

Available Tools and Resources

The Joint Commission works with over 20,000 healthcare organizations in more than 70 countries. It has published a 2-page fact sheet titled "Non-pharmacologic and non-opioid solutions for pain management." The Joint Commission has also published "Pain Assessment and Management Standards for Hospitals" which has guidance on leadership, performance improvement, medical staff, and provision of care, treatment, and services.

Promising Practices

MyStrength
myStrength helps fill the gap between generalized pain management and prescription opioid use through education, encouragement and evidence-based pain management tools. myStrength, Inc. is a recognized leader and one of the fastest-growing digital behavioral health companies in the US. myStrength enhances traditional care models while addressing issues of cost, lack of access and stigma in order to deliver mental health and well-being resources at scale. The platform targets the most prevalent and costly behavioral health conditions, empowering consumers with innovative self-care resources to manage and overcome challenges with depression, anxiety, substance use disorders and chronic pain. myStrength collaborates with over 100 health plans, community behavioral health centers, integrated health systems and Acountable Care Organizations.

Little Falls, Minnesota's Program to Reduce Opioid Prescriptions for Pain
In 2014, doctors in Little Falls, Minnesota noticed that there were a large number of opioid prescriptions and drug-related arrests. Through heightened addiction treatment and monitoring of prescriptions - as well as working with community partners like schools, local health departments, law enforcement, and health alliances - they were able to wean 324 patients off opioids entirely and lower prescriptions of opioids from 48,000 a month to 37,000. Patients must sign a contract when they are prescribed opioids that allows for electronic monitoring of their medical records to look for patterns of abuse, and law enforcement will alert doctors if opioids the doctors prescribed are found in possession of someone other than the patient to whom they were prescribed. Patients caught selling and abusing opioids are not punished; rather, they are given access to Suboxone and to a support team - including a nurse and mental health specialist. Although the program started off as an abstinence-based program, doctors changed to a medically-assisted program when patients started to die.

This program has gained national attention and is currently being looked at by national policymakers. For example, On March 6, 2017, Minnesota State Representative Ron Kresha authored a bill designed to help more Minnesota communities develop opioid abuse prevention programs based on the program in Little Falls, MN. H.F. No. 2140 would establish opioid abuse prevention pilot projects throughout the state with appropriate funding. Each pilot project would establish a multidisciplinary controlled substance care team, deliver health care services and care coordination to reduce inappropriate use of opioids, address any unmet social service needs that create barriers to managing pain effectively and obtain optimal health outcomes, provide prescriber and dispenser education, promote best practices related to opioid disposal, and engage community partners outside the health care system in such efforts. The bill is currently going through revisions in Minnesota's house and senate. Minnesota is all currently taking applications for places interested in starting pilot programs based on Little Falls' model Opioid Abuse Prevention Pilot Projects